South West Surgical Club Autumn Meeting 1992

s of papers given at the Autumn Meeting held at the Royal United Hospital Bath October 23rd and 24th 1992 COLOUR DUPLEX SCANNING IN THE INVESTIGATION OF PERIPHERAL VASCULAR


Royal United Hospital, Bath
Non-invasive assessment of lower limb arterial disease may be used to select those cases which would be amenable to angioplasty.
Fifty-four limbs from 40 patients presenting with claudication or critical ischaemia were studied prospectively.
Intra-arterial DSA and colour duplex scanning (HDI, ATL) of the femoral and popliteal arteries was performed on all limbs.
The iliac vessels were scanned in 12 limbs.
In the superficial femoral artery, 28 of 29 occlusions were correctly diagnosed and 19 of 21 stenoses. In the iliac vessels 8 out of 9 significant lesions were correctly detected. In every case the duplex scan was able to predict correctly whether the lesion would be suitable for angioplasty.
Duplex scanning is a highly accurate, non-invasive means of diagnosing the site and nature of vascular lesions, predicting those patients who would be appropriate for angioplasty. This would reduce the number of patients undergoing unnecessary angiography with its inherent risks and allow for more efficient usage of the angiography suite. Angioscopy is becoming a popular new tool in vascular surgery but after initial enthusiasm will it find a place in routine work? The initial combined experience of the BRI and the RUH of using angioscopy for vein preparation in femoropopliteal has been collated. Twenty patients have been studied, all have had in situ vein femoro-popliteal bypass for critical ischaemia. The procedure was performed using the standard groin and popliteal approaches but valve lysis was undertaken under angioscopic control. Side branches were identified by the scope and small incisions made to allow branches to be ligated.
The initial results are favourable, hospital stay was significantly shorter in these patients when compared with matched historical controls. Further work will be undertaken in the two centres to further evaluate this "minimally invasive" technique but from our initial experience angioscopy is not just a new toy. A 23 year span, from 1967-1989 inclusive, was studied using retrospective data, namely operative theatre records, histopathology and cytology files. The series was first presented in 1990 and has now been updated prospectively for 1990 and 1991. All histopathological (16) and cytological (8) material has been reviewed and re-evaluated.
The follicular problems will be discussed in detail. From this modest sized series significant clinical, operative and cytohistological difficulty was recorded in 10/16 (62%) of patients. The cytopathology of CLT, non-toxic hyperplasia of childhood and the papillary neoplasms was significant and requires emphasis. Conclusions are tentative. They are: (1) The valuable status of fine needle aspiration cytology under a brief general anaesthesia if necessary -for all goitres.
(2) A need for greater recognition of the prevalence of C.L.T.
in this age group.
(3) The value of per-operative frozen section diagnosis in neoplastic cases to influence the extent of surgery.
(4) The exacting 'borderline diagnosis' between non-toxic hyperplasia and follicular adenoma. The ever increasing trend towards larger surgical centres with sub-specialisation has recently been encouraged by Politicians, Managers and Royal Colleges.
In practice, the adequately staffed District General Hospital Surgical Department can deal with the majority of cases without referral to Tertiary centres.
In East Somerset, where over 25% of all the Family Doctor referrals are to the General Surgeons, Clinical Audit has confirmed less than one handful were sent elsewhere.
At present the main reasons for transfer are for expensive high technology therapies which could be provided on a yisiting mobile basis for the District Hospitals. Only one Person out of 4,800 patients studied was sent elsewhere for iagnosis. The correct provision of on site surgical resources ^ith visiting treatment pantechnovans removes the need for large regional centres and provides an equitable distribution of quality Health Care.
local recurrence after locally curative J-OLORECTAL CANCER RESECTION Thompson ?ucestershire Royal Hospital published big differences in rates of local recurrence after curative resection of colorectal cancer need explaining. 1 e is being compared with like and the reports are correct, Cn some surgeons are more successful in eradicating the disease from its primary site than others. One possible source of trouble is exfoliated colorectal cancer cells, which have been shown capable of implantation and growth. Another is failure, in the case of rectal carcinoma, to excise the entire mesorectum.
To illustrate management of both threats the outcome in all 107 cases of rectal cancer treated by locally curative resection between 1985 and 1991 is presented. There were only three local recurrences but even so it is argued that each could have been prevented.
The study suggests that in all except locally palliative resections (when the primary is peeled or finger fractured from irremovable adjacent structures and regrowth would be inevitable) local recurrence after locally curative procedures is an avoidable tragedy. Whether the technique of on- Overall, 19 grafts (25.3%) failed within the first 30 days (2 others were salvaged after occlusion) and 20 amputations were required (5 despite patent grafts). There were 2 early deaths (mortality 2.7%).
At the end of the five year period a total of 37 patients had required amputation (0-21 months, median 1 month after operation), and 18 had died. Nineteen (40% of survivors) were alive with patent grafts. These disappointing early results were due to an initial technical learning curve, after which increased confidence led to reconstructing patients with inadequate distal arteries. Latterly, a more selective approach, with extension of operating time to revise imperfect results as required, has produced improved graft patency. Limb salvage can be achieved in a worthwhile proportion of these patients. IS  years, median 71) of whom 48 had proximal and 131 infrainguinal procedures (some had both), prior to introduction of duplex graft surveillance. During the followup period of 30-66 months 100 patients had died or required amputation. The 85 remaining 73 were invited for review by examination and structured questionnaire, and 64 (87%) attended.
These patients had a median of 1 postoperative review (range 0-6)which 68% found helpful for reassurance, and only 26% would have preferred another. They had been told to report immediately if concerned, and 27 (42%) had done so. Fourteen (22%) had reoperations. 80% grafts remained patent.
Minimal outpatient followup is acceptable to most patients, and most present if symptoms of graft occlusion develop, provided they have been told to do so. Further routine review should be restricted to appropriate vascular laboratory surveillance of selected grafts.